Providing Insights that Contribute to Better Health Policy

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Pressures Intensify for Hospital Emergency Departments

cross the 12 HSC communities, the traditional role of physicians taking emergency call as part of their obligation for hospital admitting privileges is unraveling, posing risks that insured and uninsured patients, alike, may not get timely and appropriate care (see Data Source). Emergency on-call coverage refers to having a physician with the appropriate specialty expertise available 24 hours a day to treat patients. While adequate on-call emergency coverage is predominantly an issue for hospital emergency departments (EDs), it also is increasingly a problem for inpatients requiring urgent specialist consultation.

Two years ago, HSC researchers reported on the range of pressures faced by
hospital EDspressures that continue today and are hindering hospitals
from securing adequate emergency on-call coverage.1 Among
these pressures is an increased demand for emergency services that is outpacing
population growth. In the past decade, the rate of overall ED utilization rose
7 percent, increasing from 36.9 to 39.6 visits per 100 persons.2
Ensuring the efficient flow of patients through the hospitalso-called
throughputalso is a continuing challenge for hospitals, and delays in
obtaining specialty services contribute to crowding when ED patients must wait
to be seen by a specialist.

While insured people account for the vast majority of ED visits in the United
States, the proportion of visits by uninsured people is rising at a relatively
higher rate. The uninsured, or self-pay patients, accounted for 14 percent of
ED visits in 2003, rising to 16 percent in 2005.3 Respondents
across the 12 communities largely attributed the increase to the growing number
of uninsured people, including immigrants.4 As a Cleveland
hospital chief financial officer said, The uninsured are accessing our ED more
because they are finding it harder to get into private physician offices, I
think because of a focus on payment in those offices.

Growing Reluctance to Take Call

lthough a problem for the past decade, recent reports by
hospital executives and other market observers in the 12 communities indicate
a worsening situation around hospitals ability to obtain emergency on-call
coverage, fueling tensions between hospitals and physicians. As one Seattle
market observer noted, I think that the ED coverage of care issue is much more
salient than two years ago. Weve had many meetings about sharing the burden
around the city and the problem is getting worse. Nationally, 73 percent of
emergency departments report inadequate on-call coverage by specialist physicians.5
Specialists who are particularly difficult to secure for on-call coverage include
orthopedic surgeons, neurosurgeons, plastic surgeons, trauma surgeons, hand
surgeons, obstetrician-gynecologists, neurologists, ophthalmologists and dermatologists,
according to hospital executives.

In some cases, a shortage of certain specialists contributes to inadequate
on-call coverage. But physician unwillingness to take call appears to be a more
pressing issue for many hospitals, compounding larger workforce issues of physicians
not choosing specialties or practice locations that better align with the medical
needs and geographic distribution of the population.6 According
to a Little Rock hospital executive, for example, There are tons of neurosurgeons.
They are all trying to figure out how to not take ER call, which generates an
artificial shortage.

Why Specialty Physicians Avoid Taking Call

istorically, physicians provided on-call emergency coverage
in exchange for hospital admitting privileges, which allowed them to connect
with new patients and helped build their practices. In addition, heavy public
subsidization of medical education and residency training traditionally has
been accompanied by an unwritten social contract for physicians to maintain
the core competencies of their specialty in hospitals where they practice and
to provide some emergency call.7 Hospitals enforce on-call
requirements through medical staff bylaws or other contractual arrangements
with physicians. With many specialists now shifting the focus of their practices
away from hospital settings or to specialty hospitals that dont have EDs, they
are less reliant on hospital admitting privileges to care for their patients
or to maintain a practice.

Payment for emergency care, and physician services in general, is another factor in specialists reluctance to provide on-call coverage. Many physicians believe payment for care provided while on call is inadequate, and when they are required to care for uninsured patients, the situation becomes untenable. Time spent by a physician seeing ED patients has an opportunity cost in terms of time away from insured patients in their office practice. According to a Syracuse hospital executive, They [physicians] look at ED call as a burden. It affects quality of life and finances in a negative way.

Specialists also are concerned that providing ED care increases exposure to medical liability and may result in higher malpractice premiums. A Lansing physician noted, All over the country there is an unwillingness of physicians to take ER call. It does have to do with the lack of reimbursement, but also the malpractice issue. Usually big trauma cases and more challenging cases carry more riskthats the perception, at least.

Moreover, so-called microspecialization among physiciansfor example, an
orthopedist who focuses only on hand surgeryhas added to the reluctance
of surgeons to provide on-call coverage for more routine emergency conditions
they believe are outside of their narrow subspecialty. A Phoenix market observer
lamented, Now, we have very specialized specialists and, because of liability,
they dont want to go outside of their area. Given training requirements, however,
most specialists possess the core competencies that qualify them to provide care
for the majority of routine, but urgent, conditions that present in a general
hospital.8

Physicians reluctance to provide emergency on-call coverage also is influenced by quality-of-life issues. Many physicians dislike providing coverage because it requires them to be available 24 hours a day. During the day, this may oblige physicians to leave their practice to respond to an emergency call. In the evening or on weekends, call coverage may interfere with family or other personal obligations.

Adverse Patient Outcomes

here is evidence that specialist physicians reluctance
to provide emergency on-call coverage is contributing to adverse patient outcomes.
Twenty-one percent of patient deaths or permanent injuries related to ED treatment
delays are attributed to lack of availability of physician specialists.9
Across the 12 communities, market observers said that ED patients are waiting
longer for specialty care.

In some communities, there is a complete lack of access to routine specialty
care in the emergency department, forcing patients to either travel long distances
or be transferred to another hospital for fairly routine but urgent needs, such
as uncomplicated fractures. In Little Rock, a hospital respondent gave the example
of a patient with hand injuries being transported to another state for care
because a specialist was not readily accessible. Such situations can result
in prolonged patient suffering and inconvenience, and in some cases a second
ED visit and ambulance bill. Two-thirds of ED directors in level I and II trauma
centers say that more than half of all patient transfers they receive stem from
lack of timely access to specialist physicians at the referring hospital.10

Finally, the specialist on-call coverage issue places
a disproportionate burden on physicians willing to provide coverage, increasing
the potential for adverse patient outcomes as the workload increases and morale
declines. As fewer physicians agree to take call, specialists who provide on-call
coverage in some areas must cover multiple hospitals on the same night. One
Seattle ED director described this as a huge stress [on physicians]: Specialists
feel that they signed up to cover one hospital and now theyve got all of them.

How Hospitals Secure Emergency Coverage

ospitals are pursuing a variety of strategies to secure specialist emergency on-call coverage, including enforcement of hospital bylaws requiring call, payment for on-call coverage, paying professional fees for patients who are unable to pay, and other administrative arrangements aimed at improving the physician work environment.

Advances in medical technology, coupled with the development of physician-owned surgery, imaging, diagnostic and other facilities, have prompted the movement of many services to non-hospital settings. Consequently, many specialists no longer need general hospital admitting privileges to maintain a viable practice. Still, in some markets, there remains sufficient leverage for hospitals to enforce medical staff bylaws that require physicians to provide on-call coverage. A Little Rock health plan, for example, requires physicians, as a condition of participating in its network, to maintain the highest level of hospital privileges, including providing on-call emergency coverage, unless the physician is mainly an office-based primary care practitioner. A plan respondent said, We still believe in call coverage with specialties. We believe that the oversight in the hospital setting, peer review and rubbing elbows with peers is good for quality. A Miami hospital ED director reported that his hospitals medical staff bylaws require physicians to come in within an hour for a consult, otherwise, the CEO calls them.

Some hospitals are securing emergency on-call coverage via contracts with physician groups that take responsibility for ensuring emergency coverage. This is a model used in some areas of high population growth and few medical training programs, such as Phoenix, but it is also used in smaller cities, such as Syracuse, where direct employment of specialists may not be feasible.

Some hospitals pay particular specialists a monthly or daily stipend for being
on call. A recent national survey found that 36 percent of hospitals paid at
least one type of specialist, most often a general surgeon, to take ED call.11
Some hospital respondents find that it is politically more expedient to pay
stipends or provide other compensation in a competitive marketplace than to
enforce medical staff bylaws. One Miami hospital used an external consultant
to determine a fair-market stipend rate for physicians to provide emergency
on-call coverage. The hospital dropped physicians who wanted more than that
prevailing rate and, instead, employed physicians in those particular specialties
directly. A Little Rock hospital pays trauma surgeons $1,000 a night for coverage.
Hospitals in many of the other 12 communities report similar experiences for
particular specialists, most often orthopedic, trauma and general surgeons.
Paying specialists for on-call emergency coverage reportedly costs one Miami
hospital $10 million a year.

Along with the additional costs associated with paying physicians to take emergency
call, some hospitals are concerned about running afoul of the federal anti-kickback
law that prohibits any inducement for referrals of items or services reimbursable
by a federal health care program. In a recent advisory opinion, the U.S. Health
and Human Services Office of Inspector General indicated that hospital payments
to physicians to provide emergency on-call coverage could potentially violate
the anti-kickback law. In the particular situation described in the advisory
opinion, however, the Office of Inspector General found that adequate safeguards
were in place to protect against the arrangement being used to induce referrals.12

In lieu of stipends, and increasingly in addition to stipends, some hospitals pay physicians for each uninsured patient they treat when on call. For example, some hospitals in Little Rock and Miami reported reimbursing physicians at least at Medicare rates for patients with no coverage. An Orange County hospital guarantees physicians Medicare rates plus 20 percent for treating certain uninsured patients.

An increasing number of hospitals are moving beyond contractual or stipend
arrangements toward a direct employment model with specialist physicians. Along
with securing on-call coverage, hospital employment of specialists may be part
of a larger service-line competitive strategy. An Indianapolis hospital chief
medical officer said, I suspect that most large hospital systems will employ
more specialists. I think that the hospital systems would rather employ than
subsidize. But in doing so, hospitals must be mindful of tensions with community-based
specialists, who are still a significant source of referrals. As one Boston
physician noted, Hospitals are employing physicians, who [in turn] are taking
patients from physicians in private-practice. And then they are asking private
practice docs to cover the ER at high risk with no compensation. One Phoenix
hospital employs neurosurgeons, plastic surgeons and trauma surgeons directly,
but for political reasons, first offered emergency on call to private physicians
and allowed them to decline. Because public hospitals and large academic medical
centers with training programs often have many employed physicians, including
residents and fellows who can provide emergency coverage, the ED coverage issue
tends not to be as large a problem for these institutions as for community hospitals.

A few hospitals in the 12 communities are pursuing other administrative arrangements
to encourage physicians to take ED call. A Little Rock hospital offers practice
management support and tries to identify other win-win arrangements to get
physicians to take call rather than providing additional payment. An example
of such an arrangement is working with orthopedic surgeons to develop more surgeon-friendly
operating room schedules in return for ED call. One Miami hospital puts payment
for physicians time spent providing on-call coverage into a tax-deferred investment
account that is vested after five years as life insurance. Other hospitals are
paying for physicians malpractice premiums in return for on-call coverage or
are cross-subsidizing premiums as a way to keep on-call specialty services available.

Implications

ospitals growing difficulty in securing emergency on-call coverage by specialist physicians threatens all patients access to high-quality emergency care in local communities, regardless of whether or not patients are insured. Inadequate on-call coverage creates the potential for poor quality of care leading to adverse patient outcomes. And, some approaches to addressing inadequate on-call emergency coveragesuch as stipendsadd considerable cost.

Hospitals varied strategies to alleviate the on-call coverage issue are not a panacea. Failure to address key factors contributing to the problemmarket changes that discourage specialist physicians from providing emergency on-call coverage, including reimbursement incentives that encourage them to seek the higher revenues available in the outpatient and specialty hospital settings, the rising number of uninsured people, and the high costs of medical malpractice insuranceare likely to further aggravate the situation, creating additional quality and cost pressures for the health care system.

Data Source

Every two years, HSC conducts site visits in 12 nationally representative
metropolitan communities as part of the Community Tracking Study to interview
health care leaders about the local health care market and how it has changed.
The communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing,
Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.;
Phoenix; Seattle; and Syracuse, N.Y. Approximately 500 interviews were conducted
between February and June 2007 in the 12 communities with representatives of
health plan, hospitals, physician organizations, major employers, benefit consultants,
insurance brokers, community health centers, consumer advocates and state and
local policy makers. In each community, representatives from at least two of
the larger hospitals were interviewed. Hospital representatives included the
chief executive officer, chief financial officer, chief medical officer, medical
staff president, and for some hospitals, the emergency department director.